Provider Demographics
NPI:1033245964
Name:WHITAKER, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2553
Mailing Address - Country:US
Mailing Address - Phone:618-395-7340
Mailing Address - Fax:
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-395-7340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare ID - Type UnspecifiedPENDING-PIN NUMBER